continuing education- Extractions

[Bandaid]

I read in Lounge where a former SF Soldier/Medic reported not obtaining enough training to feel comfortable performing simple extractions. Well, let's solve that little problem.

If any of you want, we can go over a few common principles/anatomy basics.

**edited to save bandwidth

[Bandaid]

Please feel free to make guesses or ask questions. To me(in this thread) there are no stupid questions or answers. Well, that statement may not be true on SOCNET. LOL

[RIT_MEDIC]

How about you just go ahead and explain the procedure(s).

I have no idea where to begin with asking questions, but am interested in learning.

Thanks.

James D

[Sneaky SF Dude]

Grip it and rip it. Nice thread Bandaid.

[Bandaid]

edited

[Huggies]

Great info, sir. My class is actually performing these techniques this afternoon, so you were just in time, thanks. BTW, Bandaid, what's your experience with prophylactic antibiotics pre-op? A suggestion from our teacher at SOMTB was clindamycin 1 hr beforehand. I hate to perform anything that could be referred to as shotgun drug treatment, but how's the prognosis for op's without such treatment?

[Bandaid]

We still have to numb up the palatal gingiva to pull this tooth.

This procedure is performed by giving what is called a Greater Palatine nerve block. I will post a pic of where the nerve exits the palate and supplies the gingiva. The exit point (foramen) or slightly anterior to it is where you will give the injection. It is located clinically about .5-1 cm toward the midline from the inside of the second molar. It's location can be confirmed by using a cotton tipped applicator to palpate the area. You will feel a softer fluctuant area when you are over the foramen compared to hard palate bone. This is you aiming point. Here is a pic that we can use for anatomy. (***edited to add, see next post for pic...oops)

The injection is given by placing the needle straight up vertically approx. 3-4 mm in depth. If you give it in the wrong place (you obtain bony contact with the needle), as long as you are in the area or slightly anterior to the foramen, the injection will still work fine.

This injection actually gives palatal anesthesia all the way from the soft palate junction forward to the canine teeth.
1. Have patient open very wide for your visibility
2. Locate foramen with palpation
3. Insert needle 3-4 mm
4. Aspirate (important as Greater Palatine artery runs through that foramen as well), then inject 1/2 carpule VERY slowly to prevent unnecessary discomfort

Only major complication is not aspirating the needle, which would allow for injection of the lido/epi directly into an artery. Bleeding/eccymosis is not a real concern for injection into such a small vessel. FWIW, If you get bloody aspirate, pull out and reinsert slightly anterior.

That takes care of basic/common anesthesia for these three teeth. Is everyone good to go? Questions, more pics needed, or should I continue?

[Bandaid]

Palate anatomy pic....

[Bandaid]

Huggies-
Routine/general use of clindamycin pre-op on patients that do not have a documented medical need ( ex. hx of Rheumatic fever, mitral valve prolapse WITH regurg., recent joint replacement, Prosthetic heart valve) is not indicated. To me, you are wasting your precious and limited quantity meds. You are also putting the patient at an unnecessrary risk for an allergic reaction.
The reasoning behind not needing Ab's for standard extractions....... you are taking the etiology or cause of the infection out of the patient when you remove the tooth. The normal immune response can then handle the residual bacteria left in the socket.

Now, if they are showing systemic signs of infection (fever, malaise), then I would agree with Ab useage. Also, a clinically large fluctuant or any cellulitis infection would also dictate use of Ab, IMO.
Good question.

note on premed- If I was working on another US soldier. If I had the time, I might pre-med the patient with 800mg of IBU 1-2 hours before. That way, when the anesthesia wears off , the med is in place. It also cuts down on postop inflammation IMO. That is not a "guideline", just my personal choice though.

[Bandaid]

To help for the actual extraction explanation part, I need to know what instruments SF medics have access to in the field. Can you order/pack what you want when in the planning stage? Or is there a predetermined generic dental kit? There are only a few items that are needed IMO, just need to know what is available.

Or do I need to give the instructions hard core UW style? You know, get out the flathead screwdriver/vice grips/sewing kit and tea bags for hemostasis route?

[Sneaky SF Dude]

predetermined generic dental kit

[Bandaid]

Could someone post a link that I can read up on exactly what dental instruments are in the kit? I know there will be basic surgical and suturing setups available in the normal med kit. Maybe at least see a picture of the instruments laid out...I can ID the instuments myself (Hopefully anyway).

I searched google,etc and only found a WWII setup to view. Although it is probably very similar to what is used even today... any help would be appreciated.

[Sneaky SF Dude]

Post the WWII set up, I'll bet its the same exact thing I had.

I can't remember all the names.

[Bandaid]

Just came across this online looking for that WWII setup again. It is from the Fort Irwin website.


Modified Dental Aid Bag*

Compartment 1
Atropine, anaphylaxis kit 2ea
Ibuprofen tabs, 800mg, bottle of 100 1ea
Penicillin, 500 mg tabs, bottle of 100 1ea
Clindamycin, 150 mg tabs, bottle 100 1ea
Lidex gel, 15 gr tube 2ea
Airway, pharyngeal large adult 1ea
Marcaine 1:200,000 can of 50 1ea
Xylocaine 2% 1:100,000 pack of 10 3ea
Envelope, self-seal, polyethylene 15ea
Floss, waxed, individual size 1ea
Stethoscope 1ea
Sphygmomanometer 1ea

Compartment 2
Gloves, sterile, pair, size (Dr. choice) 10pr
Gloves, exam, pair, size (Dr. choice) 30pr
Mask, surgical 30ea
Protective eyewear 1ea

Compartment 3
Tray instrument with lid 8x8x2 1ea
Monojet syringe irrigating 10 cc 2ea

Compartment 4
5% iodoform sterile packing strip 1ea
Sterile alcohol pads, individual 50ea
Surgical scalpel blade No. 15 4ea
Individually bagged and sterilized;
syringe, aspirating, anesthetic 2ea
Forcep, No. 23 1ea
Forcep, No. 150 1ea
Forcep, No. 151 1ea
Elevator, 34 1ea
Elevator, 301 1ea
Curette, miller No. 10, added No. 2 MOLT (my preference)2ea
Elevator, periosteal molt No. 9 2ea
Handle, surgical scalpel blade 2ea
Forceps, dressing 6" 2ea
Holder, suture needle collier 1ea
Scissors, iris, curved 1ea
Tissue forceps, addison 4.5" 1ea
Scissors, Dean angular 6 3/4", 1" cut 1ea
Mouth mirror with handle 6ea
Explorer-probe, dental -- No. 23ea
explorer/No. 4 perio probe 6ea

Compartment 5
Wire 25 gauge wire 1 oz 1ea
Splint set, arch wire dental 2ea
Pliers, diag cutting surgical wire 1ea
Bacitracin ointment 3ea
Suture sz 4-0, absorb, polyglycolic 10ea
Suture sz 4-0, nonabsorb, ethicon 5ea
Bandaids pk of 10 3ea
Adhesive tape 1 in x 10 yds, porous 2ea
4x4 sterile gauze, packs 10ea

Compartment 6
Cement, ZOE, IRM ivory, kit
(powder and liquid) 1ea
Glass ionomer cement, kit
(powder and liquid) 1ea
Spatula dental flat, mixing 1ea
Wire ligatures 10ea

Compartment 7 - side pocket
Pen, black ink 2ea
SF Form 603 20ea
Small memo pad 1ea
Endo files, 25 mm set 10-40 2ea ***left this in for a future thread I want to do on SOCNET
Wire ligatures 10ea

I know all this would be a pain to bring. However, most of the stuff on the list already has dual function as medical supplies. Anyway, this can be a wish list for you potential SF part time sacamuelas.

Believe it or not, I deleted a BUNCH of crap off the original bag's inventory. It would be a pretty good bag though IMO, we could handle just about anything head/neck with this one.

[Sneaky SF Dude]

That looks about right. There's some stuff I don't recognize and I think we had a little less, but basically that's it.

[Bandaid]

edited above post. Just wanted to clarify that I changed the standard aid bag's contents. Next post(tommorow) .... will be techniques and procedures for the extractions

[Axe]

I know almost nothing about dentistry. I am finding this very interesting, Bandaid. Thank you for your time in doing this.

[Footmobile]

Cool thread

[Doctor_Doom]

Excellent Bandaid, thanks.

[Bandaid]

edited

[TheTooth]

Bandaid,
This is exactly what is taught in Dental School. Great use of pics.
--TheTooth, Seabee Dentist

[Bandaid]

Really???? Are you sure? I wonder how that happened!!!!:D

Thanks

[Bandaid]

The tooth: check your PM's

there is more, but I am going to have to charge YOU for the CE credits. ;)

[TheTooth]

Bandaid,
If you want any pics from the operatory or the field (ie. Balikatan) let me know. I can tailor the pics to any scenario you want. Or if you want pics of the instruments, just let me know.
The Tooth

[d3b2]

Originally posted by Bandaid


3. Major Complication: The maxillary sinus lies directly above the teeth in question. In some cases, the roots are in the sinus itself. Something to remember when chasing after small fragments or when using your elevators to "push up" and wedge a root out (which can push the fragment up into the sinus).


what happens when you push a fragment of the molar into the maxillary sinus?

I have a question about the anasthesia in the foramen. Where is the "soft palette junction"? I was just assuming that it was near the foramen which doesnt make sense because then the anasthesia wouldn't effect the molars.

great thread. thanks!

[Bandaid]

Originally posted by d3b2
what happens when you push a fragment of the molar into the maxillary sinus?
Leave it alone. Deduce/Observe how much fragment is left and document which root it came from. Document all that info (if he is a US soldier) and place on antibiotics.

The removal of a fragment is outside the capabilities of a medic, even a self-admitted "cutter" like Sneaky. You are better off leaving the area, without further attempts once you see the root fragment disappear "up" into the socket.


Originally posted by d3b2
I have a question about the anasthesia in the foramen. Where is the "soft palette junction"? I was just assuming that it was near the foramen which doesnt make sense because then the anasthesia wouldn't effect the molars.
Hard palate has underlying palatal bone underneath it. The soft palate is the posterior continuation of the mucosa that forms the upper/posterior roof of the oral cavity.

Easy way to distinguish the line... Hold patients nose pinched closed with his mouth open wide. Observe the roof of the mouth. While focusing on the roof of the mouth, have the patient attempt to blow air out of his nose. You will observe the more posterior area of the mouth drop/pivot down from the pressure building in the nasopharynx. It will look as if it bends down in a perfect little crease from one side of the mouth to the other. That crease line is the hard/soft palate junction. This is because the hard palate will not pivot from the pressure due to its bony support. The soft palate is only mucosa, therefore it will move with the air pressure influence above it.

Eventually I will post on the actual procedure for extractions. Been busy lately with work and Family commitments. Good questions.

[d3b2]

Originally posted by Bandaid
Eventually I will post on the actual procedure for extractions. Been busy lately with work and Family commitments. Good questions.

great info Bandaid. I'm going to have to find somebody to let me look in their mouth for the palate junction now ;)

Be well with family.

[Sneaky SF Dude]

The removal of a fragment is outside the capabilities of a medic, even a self-admitted "cutter" like Sneaky.

WTF? BLASPHEMER!




LOL - he's right of course. I wouldn't go after it. The point is not to let it happen in the first place.

[RIT_MEDIC]

Originally posted by Bandaid
Leave it alone. Deduce/Observe how much fragment is left and document which root it came from. Document all that info (if he is a US soldier) and place on antibiotics.

The removal of a fragment is outside the capabilities of a medic, even a self-admitted "cutter" like Sneaky. You are better off leaving the area, without further attempts once you see the root fragment disappear "up" into the socket.


If you dont mind could you outline the treatment for above problem in the event this occurs. Also any insight into other problems this could create and S/S for additional problems.

Thanks,

James D

[Bandaid]

Procedure for removal of root fragment displaced into the maxillary sinus.
*** Note, this is NOT a field treatment/should not be attempted unless fully qualified and experienced to perform this surgery. There is never a situation in SF medicine for this to be attempted in the field. Again, put on Ab and Evac to a Oral surgeon/ENT/or Stud general sacamuelas. Due to its unlikely application to SF medicine, I will cover it in a generic way without the necessary detail to perform the surgery.

As far as S/S after the root fragment is displaced, you usually observe none initially. The effects are a potential for sinus infection, continuous sinus congestion/inflammation, creation of oral/sinus fistula, and cyst formation around fragment. Frequently, you will observe blood/fluid drainage thorugh the nose as well.

Procedure I learned is called the Caldwell Luc procedure.

***Note: To save myself typing time, I pasted this here after cleaning it up. The following is actually taken from LCDR Lena Hartzell.

CALDWELL-LUC PROCEDURE:
1. Creates an opening into the nose at the level of the sinus
2. Allows for good visualization

Technique:
1. Anesthetic best suited for the patient
2. Upper lip is elevated with retractors
3. U-shaped incision is made through the mucoperiosteum to the bone
4. Tissue is elevated from the bone with periosteal elevators going superiorly as high as the infraorbital canal
5. An opening is made into the facial wall of the antrum above the bicuspid roots by means of chisels, gouges, or dental drills
6. The opening is enlarged by means of bonecutting forceps
7. The opening should be made high enough to avoid the roots of the teeth in that area
8. The cavity is cleansed with saline solution
9. Removal of root fragment
10. The soft tissue flap is replaced
11. The flap is sutured over the bone with multiple, interrupted black silk sutures
** If it is a chronic case, an antrostomy needs to be performed to allow for drainage through the nasal cavity.
*** Regardless of the technique, it must be remembered that the osseous defect surrounding the fistula is always larger than the clinically apparent soft tissue. Surgical planning of closure technique should be adjusted accordingly.

Indications:
Removal of teeth and root fragments in the sinus
Trauma of the maxilla
Management of hematomas of the antrum with active bleeding through the nose
Chronic maxillary sinusitis with polypoid degeneration of the mucosa
Cysts in the maxillary sinus
Neoplasms of the maxillary sinus

Complications:
Recurrent sinusitis
Anesthesia of the cheek and teeth
Persistent cheek swelling
Dental complications

Prevention:
Treatment planning
Careful observation
Evaluation of radiographs for divergent roots and proximity of roots to the sinus
Use of correct surgical technique As Sneaky said
Knowing when to refer

Post-operative care:
No forceful blowing of the nose
No use of straws
No smoking
Keeping mouth open when sneezing
Soft diet for several days
Antibiotics (PCN, Amoxicillin, or Clindamycin)
Nasal decongestants: Systemic: Sudafed Local: Neosynephrine

[RIT_MEDIC]

Thank you.

[Bandaid]

Your welcome James. Good questions....

[TheTooth]

Field Dentists/Medics,
When extracting well anchored teeth without the aid of a high-speed drill to removal surrounding bone, roots will likely break. Don't worry, by removing the offending portion (ie. carious crown, fractured crown, etc.) you are helping the patient. Without a drill to remove surrounding bone it is next to impossible to remove root tips and is best to just leave them be. Many times the patient will start to feel relief within a day or two and over time the root will exfoliate itself when left alone. If a maxillary root tip gets relocated to the sinus, just leave it alone. It is much easier to retrieve it in the operatory under ideal conditions if someone hasn't gone root tip fishing.
Question: What type of local anesthetic are you guys being taught to administer?
Keep up the good work guys.
-Matt

[Bandaid]

FWIW, I don't agree with most of the last post.

[RIT_MEDIC]

Originally posted by Bandaid
FWIW, I don't agree with most of the last post.


Could you expound a bit on that Sr Sacamuelas.

James D

[Bandaid]

James asking me to sharp shoot??? LOL

The tooth was misunderstood by me.

[RIT_MEDIC]

Originally posted by Bandaid
James asking me to sharp shoot??? LOL... Does that help James?

I did not intend to place you into a position to sharp-shoot Bandaid. I was just seeking clarification on the issues above. :D

"I see", said the blind man as he spat into the wind. "Its all coming back to me now."

Thanks again,

James D

[TheTooth]

Bandaid,
My apologies on derailing your topic. You are correct on your dissection of my post. I did not translate my thoughts into words very well. I was pigeonholed in my thoughts of people extracting maxillary molars with diverging roots with only an elevator and general forcep. Sometimes (less than 10%), a root tip fragment will break and remain in the socket. When this happens, the removal usually calls a combination of root tip elevator, ronguer, drill, or root tip forcep. My main point which I did not clearly convey was, it is better to leave small (<2mm) root tip fragments in the socket than to chase them.
Matt

[Sneaky SF Dude]

Nothing wrong with a little sharpshooting every now and then, as long as its done in a professional manner, as it was in this case.:D

[Bandaid]

No need to apologize Tooth... I figured I might be slightly misinterpreting your words. That is why I initially only posted that I disagreed. I didn't want to post all that.... James made me do it! ;) LOL I just didn't want the guys who will be faced with this dilemna to think that its "okay" to leave roots. To me , its not in 99% of the cases. Leaving roots should always be a LAST resort. When that decision is made the only factor involved should be "do no harm" not don't try because its harder/takes more time, IMO. That is what I wanted to get across.

thanks for not taking that personally ....

[RIT_MEDIC]

Originally posted by Bandaid
I didn't want to post all that.... James made me do it! ;) LOL...

Did I now? ;) lol Hows that arm? Hope I did not twist it too far. lol

James D

[Sneaky SF Dude]

Ok, kumbaya time is officially over you two:D

Get back to grippin' and rippin'

I would like to see a thread on sacamuelas (in general) recommendations on preparation/prevention measures prior to deployment.

[Bandaid]

I know James... LOL
I admit it. :o I did try to be "nice" though. You know, be more like that wuss Doc Doom. oops....there I go again. HaHa

On a joking side: I really wanted to use Sneaky's famous SOCNET line,
" So we agree, I am RIGHT and you are wrong. "

Couldn't do that to The Tooth though. He seems to be a good guy.

Kumbaya..... yeah that is what I am known for in this forum Sneaky. LOL I thought I was the resident smart ass/sharpshooter.

Will do on your suggestion. Gotta finish this one first....

[Doctor_Doom]

Originally posted by Bandaid
I did try to be "nice" though. You know, be more like that wuss Doc Doom. oops....there I go again. HaHa

Sneaky said professional sharpshooting, dammit!!!!